Provider Demographics
NPI:1215479316
Name:FENTON, JONATHAN (LGPC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:FENTON
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 ALDEN RD
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-5625
Mailing Address - Country:US
Mailing Address - Phone:847-736-0637
Mailing Address - Fax:
Practice Address - Street 1:10176 BALTIMORE NATIONAL PIKE STE 110
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3651
Practice Address - Country:US
Practice Address - Phone:443-720-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MDLGP13243101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health